Intestinal Diseases

Peritoneal Tuberculosis

Introduction

Abdominal Tuberculosis is very common presentation in the Indian subcontinent. There are no specific symptoms in patients with abdominal tuberculosis except abdominal pain and weight loss. It can occur along with Pulmonary Tuberculosis (tuberculosis of the lungs). A nearly diagnosis is a preferable to start medical therapy for complete cure. Also, this helps control disease process in the patient and in the community, in general.

Symptoms

1.       Abdominal pain – This is the most common symptom seen in patients with abdominal tuberculosis. Also, 10% patients may never have had any abdominal pain. The type and severity of pain is also very variable. It may be a dull ache, an intermittent pain, fullness after food, gas pain or severe cramps like pain with bloating and vomiting. The last presentation is usually a feature of an acute presentation.

2.       Weight loss - Usually, weight loss is a presenting symptom. Some people may present with considerable weight loss.

3.       Poor Appetite - This leads to reduced intake which in turn causes weight loss.

4.       Diarrhea - Sometimes, abdominal pain may be even severe cramps with severe diarrhea and rapid weight loss. These are alarming signs and suggest possibility of tuberculosis.

5.       Fever - Almost 80% of patients with tuberculosis have fever. The fever pattern is variable ranging from high grade with chills or constant low grade.

6.       Nausea, vomiting

7.       Bloated abdomen due to accumulation of fluid inside the abdomen

8.       Abdominal lump

10.   Sudden acute presentation with abdominal pain, vomiting, bloated abdomen and inability to pass gas and / or stools due to a block in the intestine. This block can be from outside as intestines tend to get stuck to each other, from within the bowel due to narrowing of lumen.

11.   Others - Cough with or without sputum, Blood in cough, weakness, easy fatigability, swelling in the neck, axilla (enlarged lymph nodes).

Investigations

1.       Hemoglobin - usually low

2.       WBC count - raised lymphocyte count

3.       CRP - usually raised

4.       X-ray Chest abnormal in presence of pulmonary tuberculosis

5.       Mantoux test is positive due to exposure to the bacilli

6.       Ultrasound abdomen may suggest free fluid, lymph nodes, splenomegaly.

7.       Computerised tomography may show free fluid, lymph nodes, abnormal narrowing of bowel, clumping and adherent small     bowel forming a lump.

8.       Staining of this fluid may show tubercle bacilli.

9.       Diagnostic Laparoscopy helps in diagnosing the condition, almost 90%. Fluid examination, biopsy of lymph nodes, peritoneum help diagnosis. Laparoscopic helps avoid major abdominal surgery in such situations.

Treatment

In addition to taking standard anti-tubercular treatment, proper diet is equally important. Also, treating the symptoms of the patients is equally important especially in patients with abdominal tuberculosis.

Discussion

Abdominal Tuberculosis is a common differential diagnosis in India in view of its prevalence. The problems in treatment of tuberculosis are many and include

1.       The late presentation

2.       Vague symptoms

3.       Difficulty in identification of tubercle bacilli

4.       Long treatment schedule

5.       Drop-out in treatment due to improvement of symptoms in a few weeks.

These above factors have contributed to the emergence of standard drug resistance.

Most common differential diagnosis

1.       Intra-abdominal malignancy

2.       Liver disease

3.       Pancreatitis

Peritoneum is the innermost layer of the abdominal wall, similar to the skin on the outside.

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